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1
Q

How do ankle fractures usually present?

A

Acute pain and swelling following trauma

2
Q

MC injured wt bearing joint of the body, that has increasing incidence in the elderly and diabetic populations?

A

Ankle fractures

3
Q

OA and fractures?

A

They are going to get OA

Primary ankle OA = 7-9%
Post-traumatic = 70-78%

4
Q

What comprises the mortise of the ankle?

A

tibial plafond
Medial malleolus
Lateral malleolus

5
Q

Stability in the ankle?

A

Bony articulation is more stable with dorsiflexion

A highly congruent joint

6
Q

Lateral ligamentous complex?

A

Anterior talofibular ligament

Posterior talofibular ligament (strongest)

Calcanofibular ligament (limits inversion)

7
Q

Anterior, posterior and inferior stability of the ankle joint?

A

Anterior-inferior tibiofibular ligament (AITFL)

Posterior-inferior talofibular ligament (PITFL) - volkmans tubercle

Inferior transverse ligament (ITL) (part of the PITFL?)

8
Q

Ankle’s always swell, how does this affect treatment?

A

Medial, lateral and or posterior swelling can lead to infections and problems with the surgery so often must wait for the swelling to go down before cutting the pt

9
Q

Common exam findings with ankle fx?

A

Swelling (medial, lateral, posterior)

Tenderness at fx site

Palpable gap on medial side (maybe)

External rotation or lateral displacement (maybe)

10
Q

A distal fib (lateral malleolus) fx w tenderness over the medial deltoid ligament is presumed to be?

A

Unstable bimalleolar injury until proven otherwise

11
Q

What must always be assessed with ankle fractures? Or any other fx for that matter

A

Assess circulation and innervation to posterior tibial, superficial peroneal and deep peroneal nerves distal to the fx

Lacerations assessed for open fractures

12
Q

What radiology needs to be ordered for most ankle fx?

A

AP
Lateral
Mortise

13
Q

What is a mortise view?

A

15* internally rotated AP

The relationship of the tib, fib and talus are the clearest with the mortise view

14
Q

Danis weber classifications?

A

Weber A: below the joint
- fibular fx is distal to ankle mortise

Weber B: at the joint
- fibula fx oblique and begins at the level of the ankle mortise and extends proximally

Weber C: “train wreck”

  • tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
  • medial malleolus fracture or deltoid ligament injury present
15
Q

Danis webber A treatment?

A

Closed reduction with casting

16
Q

Danis-weber B treatment?

A

Closed reduction and casting

17
Q

Warning sign of badness for danis weber B?

A

stress exam reveals medial clear space widening > 5mm

Makes treatment more complicated

18
Q

What is a manual stress view?

A

Assess the integrity of the deltoid ligament medial clear space

With Ankle in maximum dorsiflexion external rotation force is applied to the foot-mortise view is obtained

19
Q

Radiology techs always want to pull on the ankle to get a stress view but what is the best way to do it?

A

Gravity has been shown to be equally effective and much less traumatic to the pt

(Hang the leg ff the table and get your x ray)

20
Q

Danis-webber C treatment?

A

Open reduction with internal fixation (ORIF)

21
Q

What are bimalleolar injuries?

A

Fractures of the lateral and medial malleolus or fracture of the distal fibula with disruption of the deltoid ligament

22
Q

What fracture is associated with syndesmotic disruption?

A

Maissoneuve fracture

23
Q

What is a tillaux fracture?

A

Avulsion injury of the lateral tibial articular surface (anterior or posterior) (ATFL)

More common in kids because in adults the ligament is weaker than the bone so the ligament gives out first

24
Q

Trimalleolar injury

A

lateral malleolus, the medial malleolus, and the distal posterior aspect of the tibia (aka posterior malleolus)

May also include posterior dislocation of the ankle

25
Q

Why are trimalleolar fractures a big deal?

A

They are highly unstable and hard to reduce

26
Q

Initial treatment of all ankle fx?

A

Reduce dislocations (ASAP)

Non-weight bearing L&U splint

Call ortho

27
Q

How is a closed reduction performed?

A

Anatomic reduction of the mortise using the Quigley maneuver (suspended great toe)

Then

Well padded L and U splint with good proximal, distal and apex molds, ankle in neutral flexion

28
Q

Ankle reductions hurt, what is an alternate to conscious sedation to perform the procedure?

A

PRC - intraarticular hematoma block

20ga needle into medial ankle, medial to the TA tendon , hematoma is aspirated and 12cc of lidocaine is injected in its place

29
Q

How are weber a’s treated?

A

Stable fx

Like an ankle sprain can be immobilized or put in a non weight bearing or partial weight bearing cast

30
Q

How are weber B and C or bimalleolar fractures treated?

A

Unstable

Open reduction and internal fixation

31
Q

What do unstable or displaced fractures require?

A

Closed or open reduction

Usually open reduction has the best joint function prospects

32
Q

What do all open fractures require?

A

Immediate surgical debridement

33
Q

What type of fracture accounts for 10% of fractures?

A

Foot fractures

34
Q

What is a pseudo-jones fracture?

A

MC foot fracture:

avulsion of the 5th metatarsal proximal tuberosity

35
Q

Adults vs kids?

A

Fractures are more common than sprains in kids

36
Q

When do stress fractures usually occur?

A

After a sudden increase in activity or change in factors (i.e. surface you run on)

37
Q

What will metatarsal fractures look like on exam?

A

Swelling
Ecchymosis
TTP over the fx

38
Q

What factors are not criterial for ottawa guidelines?

A

Tenders to the:

  • heel
  • 4th metatarsal
Tenderness to the: 
- lateral malleolus
- medial malleolus
- navicular bone 
Are all criteria for ottowa guidelines
39
Q

What x-rays need to be ordered for suspected metatarsal fx?

A

AP
Lateral
Oblique

40
Q

Stress fractures on x ray?

A

May not show up for 3-4 weeks so serials are needed

Or you can do MIR/bone scan

41
Q

You had a high impact injury and fractured the first metatarsal, what do you win?

A

Surgery

Play stupid games, win stupid prizes

42
Q

Zones of the 5th metatarsal?

A

Regions of the diaphysis of the 5th metatarsal metatarsal, 3 stripes

Zone 1: proximal
Zone 2: distal to zone 1
Zone 3: distal to zone 2

Look at slide 47 it will make more sense

43
Q

What is a classic jones fracture and what does that mean for the pt?

A

Zone 2 fracture of the proximal diaphysis of the 5th metatarsal

They need more extensive immobilization

44
Q

What is common with zone 3 fractures?

A

Can result in nonunion or delayed union

45
Q

Treatment of non-displaced metatarsal neck fractures?

A

Short leg cast, fracture brace or hard soled shoe

Whatever provides the minimum amount of immobilization while providing adequate comfort

They are allowed to have weight bearing

46
Q

When do x rays need to be done for metatarsal fractures?

A

At injury

After 1 week (displacement)

After 6 weeks (confirm healing)

47
Q

What metatarsal fxs get surgery?

A

Multiple metatarsal fxs

> 4mm of displacement or >10% of angulation

Zone 2 or 3 of 5th

Displaced or comminuted fx of 1st

Open fx

48
Q

The typical fx that causes injury to the 3 zones of the 5th metatarsal?

A

Zone 1: avulsion

Zone 2: jones

Zone 3: stress

49
Q

Metatarsal zones and surgery?

A

Zone 1: non operative

Zone 2: non operative (unless nonunion)

Zone 3: operative

50
Q

Adverse outcomes for metatarsal fxs?

A

If displacement or shortening occurs:

  • painful plantar callosities under metatarsal heads
  • Transfer lesions under neighboring heads
51
Q

Summary of metatarsal fx?

A

Mostly nonopp with hard soled shoe except:

  • multiple fx
  • > 4mm displacement
  • > 10* angulation
  • proximal 5th in zone 2,3
  • displaced or comminuted of 1st
  • open fx
52
Q

What is fleck sign?

A

Avulsion fx off the base of the second metatarsal or medial cuneiform signifying disruption of the lisfrank ligament

53
Q

What is a lisfrank injury?

A

Fracture-dislocations of the midfoot

Easy to miss traumatic disruption of the tarsometarsal joint

54
Q

What is the typical MOI for lisfrank injuries?

A
Significant trauma 
Or
Indirect mechanism 
- athletics
- tripping/falling off the curb
55
Q

Presentation of lisfrank injuries

A

Pt reports a sprain
Pain is localized to the dorsum of midfoot
Swelling (may be mild)

56
Q

What clinical sign is highly associated with lisfrank injuries?

A

Plantar arch ecchymosis

Specifically over the tarsometatarsal joint rather than the ankle ligaments

57
Q

How to examine a lisfrank injury?

A

Stabilize the hindfoot (calcaneus)
Rotate and/or abduct the forefoot

Lisfrank - severe pain
Ankle sprain - minimal pain

58
Q

Radiology studies?

A

AP
laeral
Oblique

Subtle injuries may need wt bearing radiographs as spontaneous reduction can occur

59
Q

What to look for on x ray?

A

AP:
Medial aspect of the middle cueniform should line up with the medial aspect of the second metatarsal

Oblique:
Medial aspect of 4th metatarsal should align with the medial aspect of the cuboid

60
Q

Your x ray shows lateral deviation of the 2nd metatarsal base

A

This is associated with a small avulsion fracture (seen with lisfrank)

61
Q

My x rays dont show anything but my exam strongly suggest lisfrank?

A

Get x rays under anesthetic

Or can do CT/MRI

36% are radiographically occult

62
Q

What does radiographically occult mean?

A

Clinical signs of a fx but nothing on x ray.

2-4 weeks later x ray shows new bone formation

63
Q

Tx for lisfrank?

A

Non-displaced:

  • 6-8 weeks of non-wt bearing cast
  • 3 months of rigid arch support

Displaced:
- surgery

64
Q

adverse outcomes associated with lisfrank?

A

Compartment syndrome (acute)

Post traumatic osteoarthritis

Instability

Sensory impairment

Deformities (claw/contracture)

65
Q

Summary for lisfrank injuries?

A

Frequently missed (have a low threshold for advanced images/consult)

Poor outcomes if missed

Displacement requires surgery

Screen for compartment

66
Q

Calcaneus fracture requires what MOI?

A

High energy (MVA/Fall)

67
Q

What needs to be r/o with calcaneus and talus fractures?

A

Spine and affected limb injuries b/c it is often from a high impact injury

68
Q

Presentation of calcaneus and talus fracture?

A

Acute pain

Instability

Inability to ambulate

69
Q

Exam for calcaneus and talus fx?

A

Swelling
TTP
Pulses may be absent (swelling)

Assess function of superficial peroneal, deep peroneal, sural, medial and lateral plantar nerves distal to fx

Palpate spine and entire lower limb for TTP

70
Q

What diagnostic studies are needed for calcaneus and talus fx?

A

AP and Lat of hind foot

Harris heel views

AP lat and mortise of ankle

71
Q

Hawkins classification of talar neck fx?

A

He said only know that II and beyond may have blood supply issues

II, III, IV are all displaced

72
Q

What is a “snowboarder’s talus fx”?

A

Lateral process of talus is fractured

73
Q

What is bohler’s angle?

A

Angle made from

  • highest point of posterior tuberosity and posterior facet of calcaneus
  • highest point on anterior process of talus

Normal is 20-40*
Decreased = fx

74
Q

Intra-articular calcaneal fx types

A

Look on slide 80 there are a bunch

75
Q

Tx for calcaneus and talus fx?

A

Immediate:

  • splint from toe - upper calf or a jones dressing
  • elevate above heart and ice x 2hrs

Surgical reduction and fixation

Rehab for ROM after fx is healed

76
Q

Adverse outcomes from calcaneus and talus fx?

A

Talar neck: blood supply -> osteonecrosis

Chronic pain
Posttraumatic arthritis
Osteonecrosis of talus
Tarsal tunnel syndrome
Complex regional pain syndrome
Plantar compartment syndrome (calcaneal or talar fx)
77
Q

Summary for calcaneus and talus fx?

A

Screen for spinal injury

Talar neck fx may lead to osteonecrosis

All require urgent ortho surg consult

Lots of after effects

78
Q

What is a phalanx fx?

A

Phalangeal fx usually involving proximal phalanx usually from direct trauma

Rarely results in major disability

79
Q

MC phalanx fx?

A

5th or little toe

80
Q

Presentation of phalanx fracture?

A

Pain
Swelling
Ecchymosis
Bony tenderness

Deformity of toe (maybe)

81
Q

Treatment for distal fx

A

Minor: buddy tap

- maybe add some padding

82
Q

Closed reduction under digital block or open reduction and pinning is rarely necissary but should be considered when:

A

Marked angulated fx

Involves articular surface of MTP joint or interphalangeal joint of the great toe

83
Q

Deformity for phalanx fx?

A

Chronic swelling and deformity are possible but unlikely

84
Q

Summary of phalanx fx

A

Who cares tape that shit together and do something useful with your life

85
Q

The hallux valgus angle is formed by a line along the first metatarsal shaft and a line along the shaft of the proximal phalanx is used to guide treatment.

What is normal hallux valgus angle?

A

<15*

86
Q

Hallux valgus aka?

A

Bunion

87
Q

What is hallux valgus?

A

Lateral deviation of the great toe at the MTP joint that leads to a painful prominence of the medial aspect of the first metatarsal head

The big toe gets forced toward the other toes and hurts

88
Q

Who gets hallux valgus?

A

Female (10:1)

89
Q

Presentation of hallux valgus?

A

Hypertrophic bursa over medial eminence of 1st metatarsal

Great toe pronated w callus on medial aspect

Can lead to numbness or tingling over medial aspect of great toe

90
Q

Exam for bunions? (normal angles and mobility)

A

Normal MTP motion

  • extension 60-90*
  • flexion 30*

Valgus angulation at the MP joint
- <15* is normal

1-2 intermetarsal angle

  • normal <10*
  • (a big v measurement of the 1st and 2nd metatarsal)
91
Q

Treatment for hallux valgus?

A

Fix your shoes
Arch support can decrease pressure if associated w flat foot

Not helpful:

  • PT
  • Splints

Surgery if disabling

92
Q

What surgery should be avoided?

Why?

A

Joint arthroplasty

High complication rate

93
Q

Hallux rigidus

A

Degerative arthritis of MP joint of the great toe and MC site of arthritis in the foot

94
Q

Describe hallux rigidus presentation

A

Pain + stiffness as toe moves into dorsiflexion
(Toe-off phase of gait)

Osteophytes usually develop on lateral side of joint

Toe is in normal alignment

95
Q

Hallmark of hallux rigidus?

A

Stiffness of great toe with LOSS OF EXTENSION AT MP JOINT

96
Q

Tx for hallux rigidus

A

Non-operative tx:

shoes to limit dorsal flexion

  • stiff-soled
  • modified steel shank
  • rocker bottom

NSAIDS

Surgery

  • excision of osteophytes
  • arthrodesis
97
Q

Keller procedure?

A

Resection of the joint

Reserved for older and lower demand patients

98
Q

Capitalism

A

Gods way of determining who is smart, and who is poor

- ron swanson